Friday, December 31, 2010

For the New Year; Less Talk About Sex, More About Unsafe Healthcare

Doug Kirby is only one in a long list of people to speculate about Uganda's 'success' in reducing HIV transmission from relatively high rates in the 80s and 90s to relatively low but steady rates in the 2000s.

As he and others wonder what happened, some sceptics have doubted if Uganda did anything in particular and have even suggested that the epidemic may have arrived, spread and declined, almost entirely independently of anything that was done to prevent it.

A lot is made of the so called ABC program (Abstinence, Be faithful, use a Condom), as if all HIV is transmitted sexually. It isn't, it never was and at one time, even in Uganda, this important fact was acknowledged.

Anyhow, no one working in Uganda in the 1980s and 1990s remembers the term ABC, it appears to have been invented later, and not even in Uganda. Also, no one seems to remember the sheer idiocy of an 'abstinence only' program, either in name or in nature. But let's indulge in Kirby's apparent sincerity as he speaks for the majority of HIV researchers.

The notion of abstinence is inherently vague; is it to abstain from sex for ever, to abstain until marriage (one of the senses used by Demographic and Health Surveys), to abstain for a period (such as during the day during the course of Ramadam), to abstain from certain kinds of sex, to abstain from sex with one's main partner, to abstain from sex with those other than one's main partner, to not have had sex for the past week/month/year, etc.

Knowledge of ABC as a whole is also deceptive because it clearly doesn't lead to the expected behaviors and HIV rates are often higher among those who appear to have higher levels of knowledge about 'safe' sex. In Tanzania, for example, knowledge is higher among wealthier, better educated, urban dwelling, 20-39 year olds, but so are HIV rates.

Indeed it has never been shown that people with the 'requisite' knowledge are less likely to be infected. In fact, those with the requisite knowledge appear to be more likely to be infected. This is not to suggest that knowing what they are taught about HIV puts people at higher risk. I am suggesting that this 'knowledge' is just not particularly relevant and it leaves out things people really need to know, such as details of non-sexual risks and how to avoid them.

None of these 'methods' of reducing the chances of being infected with HIV really amount to much. So they couldn't explain how Uganda's epidemic declined. They might have contributed a little but it's impossible to say how much. They are not really testable. They are simply based on the incorrect assumption that almost all HIV is tranmsitted sexually in African countries, so if people don't have sex, they won't be infected.

Education is a right that need have no connection with HIV or any other disease. As it happens, better educated people usually enjoy better health. But there is no useful list of causal connections between education and health. Sex, sexuality and reproduction education are also rights, but a reasonable level of general education is a prerequisite in order for people to be well educated about these issues.

Lack of knowledge about sex, sexuality and reproduction is likely to cause many problems. People growing up in ignorance of such issues face many risks, such as sexually transmitted infections, unwanted pregnancies and possibly emotional and psychological problems.

But when it comes to HIV, this area of education is not enough. People also need to know about non-sexual risks, faced in cosmetic and hairdressing facilities, tattoo and body piercing parlors, traditional healing and related contexts and, most importantly, in health and medical facilities.

If people don't know about non-sexual risks, they will not know how to take steps to avoid them. They will not know enough to check if the hairdresser sterilizes their equipment adequately, that some processes are better avoided if their safety is unknown and that in underfunded, understaffed, undersupplied health facilities, you have to check that the equipment being used is sterile, whether that equipment is new and unused or reused but properly sterilized.

If none of these measures are taken regarding non-sexual HIV transmission, no number of condoms delivered, sexual experiences foregone or anything else will guarantee protection against HIV (and other viruses, such as hepatitis B and C).

Uganda may have taken some of these precautions against non-sexual HIV transmission in the early days of the epidemic. Doug Kirby doesn't mention them much, but that doesn't mean they didn't occur. But the health access situation in Uganda is quite similar to those in Tanzania and Kenya. Most people don't have access to health services and when they do, the quality is low. But as health services spread, or as people move to access health services, HIV also spreads.

In contrast, in Southern African countries, far more people can access health services. Unfortunately, those health services are also of very low quality. So the chances of being infected in health facilities is even higher in Southern African countries. Therefore, it is unlikely to be a coincidence that Southern African countries have the highest HIV rates in the world.

Of course, I could be completely wrong, Perhaps UNAIDS are right that only 2-5% of HIV transmission comes from unsafe healthcare. Or WHO may be right that only 15-20% of transmission comes from unsafe healthcare. What I would like to see is proper investigation of health care facilities and a credible estimation of what proportion of HIV is being transmitted non-sexually (not just in health care facilities, but also as a result of traditional practices, cosmetic practices and anything else that may be involved).

We have been very unsuccessful in influencing sexual behavior and this lack of success may continue. But providing people with affordable and safe healthcare would not be nearly so elusive. And people have the right to know what the major non-sexual HIV risks are and how to avoid them. Up to now, Africans have been treated with utter contempt and, as a result, millions have been infected with HIV. Many have died and many more will die, despite all the money being churned into antiretroviral drugs.


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